PROJECT SUMMARY Rural areas in the United States (US) are facing an epidemic of opioid use disorder (OUD) and hepatitis C virus (HCV) infections. HCV is a costly infection with high morbidity and mortality and is primarily spread through injection drugs use in the US. Injection drug use is of epidemic proportions as people with OUD transition from misusing oral opioid medications to injectable forms of opioids. HCV among people who inject drugs (PWID) may be preventable through prescribed medication-assisted treatments for OUD, such as buprenorphine. However, this relationship is unclear in rural populations where OUD and HCV rates are high, but access to buprenorphine is low. Our preliminary studies also indicate marked stigma and non-evidence based prescribing habits associated with buprenorphine in rural areas. Rural community leaders have asked for this investigation. This investigation can inform practices and policies on rural populations that are disproportionately affected by the current opioid crisis. The specific aims of this research are 1) to describe differences in buprenorphine prescribing between urban and rural US population, 2012-2017 2) to assess the relationship between access to prescribed buprenorphine and HCV in rural Ohio, 2014-2017 and 3) to assess the relationship between perceived access to and use of prescribed buprenorphine with HCV status among people who use drugs (PWUD) in a rural US population in 2019. Aim 1 is informed by preliminary qualitative data from in- depth interviews with community stakeholders and will serve as a big data health care claims investigation of how buprenorphine may be prescribed less commonly and for shorter periods in rural areas. Aim 2 is an ecological spatial analysis of the relationship between buprenorphine prescribers and incident HCV in rural areas. Aim 3 is a primary respondent-driven sampling survey of PWID in rural Ohio. Aim 3 is a unique PWID- perspective of the relationship between access and use of prescribed buprenorphine and HCV infection incidence in rural populations. Each of these aims is coupled with longitudinal shadowing in infectious disease clinics locally (Ohio State) and in rural Ohio (Southern Ohio Medical Center). Additionally, we have developed a training plan that will provide unique skills otherwise not available in the current epidemiology doctoral or medical training program. I plan to have a career as an independently funded physician-scientist in infectious disease epidemiology and clinical medicine. I also plan to focus my research and clinical efforts on rural populations like those in Southern Ohio, near where I grew up, that are disproportionately impacted by injection drug use. Community-driven evidence-based interventions, in conjunction with dedicated health care and public health practitioners, are needed to end the current opioid crisis.